2022 Express Scripts Prescription Drug Coverage Guide

SERS Express Scripts Prescription Drug Coverage Guide

2022

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TABLE OF CONTENTS

WELCOME................................................................................. 2 THE SERS FORMULARY......................................................... 2

Generic Medications............................................................... 2 Non-preferred Medications...................................................... 2

PRESCRIPTION FILLS............................................................ 2 Retail Pharmacy...................................................................... 2 Home Delivery......................................................................... 3 Managing Your Prescriptions Online....................................... 3

NON-MEDICARE CO-PAYS .................................................... 4 Maintenance Refills................................................................. 4 Specialty Medications............................................................. 4 Specialty Co-Pay Assistance.................................................. 5 Non-Preferred Medication....................................................... 5 Preferred Glucose Test Strips................................................. 5

MEDICARE CO-PAYS............................................................... 6 Express Scripts Broad Performance Medicare Network......... 6 Non-Preferred Medication....................................................... 6 Medicare Part B Medications and Supplies............................ 7 Preferred Glucose Test Strips................................................. 7

COVERAGE RULES FOR ALL PLANS.................................. 8 Prior Authorization................................................................... 8 Quantity Limits...................................................................... 10 Step Therapy......................................................................... 11 Compounded Medications.................................................... 12

PRESCRIPTIONS NOT COVERED....................................... 12

Publish Date 10/2021

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WELCOME

This guide has information on prescription drug coverage for Aetna plan participants. Express Scripts administers your prescription drug coverage.

THE SERS FORMULARY

The SERS Formulary is our prescription plan's list of covered medications. It is made up of generic and brand-name medications that are high quality and cost-effective. The medications on the formulary are listed as "preferred" medications.

GENERIC MEDICATIONS Generic medications are comparable to brand-name medications. They are approved by the U.S. Food and Drug Administration, and meet the same standards as brand-name medications. However, they usually cost about half as much as brand-name medications.

NON-PREFERRED MEDICATIONS Non-preferred medications are brand-name medications not on the SERS Formulary. You pay 100% of the cost for these medications.

PRESCRIPTION FILLS

RETAIL PHARMACY Present your Express Scripts ID card when getting a prescription at a retail pharmacy.

Non-Medicare enrollees pay 100% of the cost for any maintenance medication refills at retail (see Maintenance Refills on page 4).

Medicare enrollees must use retail pharmacies in the Express Scripts Broad Performance Network for coverage (see page 6).

Only Medicare plan participants can receive a 90-day supply of medication at retail pharmacies.

If the cost of the medication is less than the co-pay, you pay the lower cost of the medication.

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HOME DELIVERY Home delivery makes sense for participants who take medication on a long-term basis. If you do not have your maintenance medication refills set up through home delivery, here is how to get started:

Contact your doctor. The fastest, easiest way to set up home delivery is to ask your doctor's office to send your maintenance prescriptions electronically to Express Scripts.

Contact Express Scripts directly. If you have questions about getting your medication delivered to your home, call a customer service representative at the number on the back of your Express Scripts ID card.

MANAGING YOUR PRESCRIPTIONS ONLINE You can set up a secure, online account to manage your prescriptions. An online account allows you to:

Order refills and track the status of orders Locate participating retail pharmacies Check the co-pay for a particular medication To set up an account, go to express-. Have your Express Scripts ID number ready. Follow the on-screen prompts to register.

DOWNLOAD THE MOBILE APP Search for "Express Scripts" in the Apple App Store or the Google Play Store.

You can order refills, track orders, start automatic refills, view your ID card, and add a reminder to take your medicine.

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NON-MEDICARE

NON-MEDICARE CO-PAYS

Generic

Retail (34-day supply)

$7.50 co-pay max.

Home Delivery (90-day supply)

$15 co-pay max.

Preferred brand 25% of cost

25% of cost

name

(min. $25, max. $100) (min. $45, max. $200)

Specialty medications

25% of cost (min. $25, max. $100)

25% of cost (min. $15, max. $67 per 30-day supply)

Only certain specialty medications allowed at retail.

Different co-pay amounts apply for medications eligible for SaveonSP co-pay assistance program.

Non-preferred No coverage brand name

No coverage

Insulin Only

Preferred brand $25 co-pay name

25% of cost (min. $45, max. $60)

Non-preferred 25% of cost (max. $45) 25% of cost (max. $115) brand name

In the event of a conflict between this information and the plan documents, the plan documents prevail.

MAINTENANCE REFILLS

Maintenance medications are drugs used to treat conditions that are considered chronic. These conditions require regular or daily use of maintenance medications.

Maintenance medications must be filled through home delivery. New prescriptions may be filled for the first two times at a retail pharmacy, but all remaining refills must be obtained through home delivery.

SPECIALTY MEDICATIONS Specialty medications typically require special handling, administration, or monitoring. They are used to treat complex and chronic conditions like cancer, multiple sclerosis, and rheumatoid arthritis.

Specialty medications must be filled by mail order through Accredo, Express Scripts' specialty pharmacy.

Accredo sends deliveries overnight. The only retail pharmacy exceptions are specialty medications that must be taken within 24 hours of a hospital discharge.

If you have questions, call Express Scripts toll-free at 866-685-2791.

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NON-MEDICARE

SPECIALTY CO-PAY ASSISTANCE SERS participates in a co-pay assistance program with SaveonSP, which takes advantage of funds available from drug manufacturers to lower your cost and the amount that SERS pays.

Accredo determines whether your specialty medication is eligible for co-pay assistance. If it is, you will be contacted by SaveonSP to enroll and lower your cost to $0. SaveonSP only contacts you if your specialty medication is eligible for this assistance. If you choose not to participate, you will pay a significant co-pay.

The specialty medications in this program are considered non- essential health benefits under the plan, and your co-pay expenses will not be applied toward satisfying the out-of-pocket maximum. If you take a specialty drug that is not included in the co-pay assistance program with SaveonSP, your prescription will be subject to the specialty medication co-pays on page 4.

NON-PREFERRED MEDICATION Brand-name medications not on the SERS formulary are called "nonpreferred." You pay 100% of the cost for these medications. You cannot receive these medications through mail order.

Insulin is an exception to this rule. Both preferred and non-preferred brands of insulin are covered.

Proton Pump Inhibitors taken to control acid reflux are not covered. Most are available as over-the-counter medications.

If you have a medical reason for taking a non-preferred brand medication, you can request to receive it at the preferred cost. Your prescriber must file a Coverage Determination Request on your behalf with Express Scripts, and provide a statement supporting the request. Express Scripts then reviews the request and sends you and your prescriber a determination.

If you reach the out-of-pocket maximum, Express Scripts pays 100% of costs until the end of the year. Non-preferred medications do not count toward your out-of-pocket maximum.

PREFERRED GLUCOSE TEST STRIPS Preferred-brand glucose test strips are available without a co-pay. You also can get a blood glucose meter at no charge to use with the preferred-brand test strips.

Non-Medicare participants should call Express Scripts' customer service number to ask which test strips and meters are free.

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MEDICARE

MEDICARE CO-PAYS

Retai Network (34-day supply)

Home Delivery (90-day supply)

Generic

$7.50 co-pay max.

$15 co-pay max.

Preferred brand 25% of cost

25% of cost

name

(min. $25, max. $100) (min. $45, max. $200)

Specialty medications

25% of cost (min. $25, max. $100)

25% of cost (min. $15, max. $67 per 30-day supply)

Non-preferred No coverage brand name

No coverage

Insulin Only

Preferred brand 25% of cost

name

$25 max

25% of cost (min. $45, max. $60)

Non-preferred 25% of cost (max. $45) 25% of cost (max. $115) brand name

In the event of a conflict between this information and the plan documents, the plan documents prevail.

EXPRESS SCRIPTS BROAD PERFORMANCE MEDICARE NETWORK

The Express Scripts Broad Performance Medicare Network is a coverage requirement for Medicare enrollees.

Enrollees must use retail pharmacies within the network or Express Scripts mail order for coverage.

The Express Scripts Broad Performance Medicare Network has a large network of pharmacies nationwide, including CVS, Kroger, Walgreens, Walmart and many more.

Enrollees filling prescriptions at a non-network pharmacy will pay 100% of the cost.

For more information on network pharmacies, create an account at express-. Once logged in, click on "Prescriptions: and then "Find a Pharmacy," or, you can call Express Scripts' Customer Service toll-free at 1-866-258-5819. (TDD: 1-800-716-3231) SERS does not maintain a list.

NON-PREFERRED MEDICATION Brand-name medications not on the SERS formulary are called "nonpreferred." You pay 100% of the cost for these medications. You cannot receive these medications through mail order.

Insulin is an exception to this rule. Both preferred and non-preferred brands of insulin are covered.

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